Fundamentals Nursing Process Questions

Correct Answer: A

Rationale: The correct answer is A because assessing the GI tract helps determine the client's readiness for feeding. Bowel sounds indicate gut motility, last BM assesses bowel function, and distention indicates possible issues. Option B is incorrect as it pertains more to neurological assessment. Option C is not a priority assessment before feeding. Option D is incorrect as formula should be warmed to room temperature before feeding to prevent GI upset.

Correct Answer: B

Rationale: The correct answer is B: 17 drops per minute. To calculate the correct drip rate, you need to use the formula: (Volume to be infused in mL / Time in minutes) x Drop factor. In this case, if the volume to be infused is 100 mL and the time is 60 minutes with a drop factor of 20, the calculation would be: (100 / 60) x 20 = 33.33 drops per minute. Since we cannot deliver fractional drops, the closest whole number is 17 drops per minute. This ensures the correct delivery rate for the medication. Choice A (6 drops per minute) is incorrect as it would be too slow and may not deliver the medication effectively. Choice C (50 drops per minute) and Choice D (100 drops per minute) are incorrect as they would both deliver the medication too quickly, potentially causing harm to the patient. The correct answer, 17 drops per minute, ensures a safe and accurate delivery rate

Correct Answer: A

Rationale: The correct answer is A: Administer oxygen therapy. This is the priority intervention because a high temperature and diaphoresis indicate potential respiratory distress. Oxygen therapy can help improve oxygenation and support respiratory function. Providing frequent linen changes (B) is important for hygiene but not the priority. Fluid intake (C) is essential but not as urgent as addressing respiratory distress. Maintaining complete bed rest (D) may be necessary but addressing oxygenation takes precedence in this case.

Correct Answer: B

Rationale: The correct answer is B because tension headaches typically present as a feeling of pressure or steady constriction on both sides of the head. This is due to muscle tension in the head and neck. Choice A is incorrect as sensitivity to light is more characteristic of migraines. Choice C is incorrect as unilateral paralysis is not typically associated with tension headaches. Choice D is incorrect as vague headache especially peri orbital is not a common symptom of tension headaches. Therefore, the best description of discomfort experienced by a client with a tension headache is the pressure or steady constriction on both sides of the head.

Correct Answer: C

Rationale: The correct answer is C: The patient is apprehensive about discharge. This is the correct answer because the patient's fear of going home and being alone indicates apprehension about discharge, which is a common feeling among patients transitioning from the hospital to home care. This subjective data suggests that the patient may need additional support and education prior to discharge to address their fears and concerns. A: The patient can now perform the dressing changes without help - This is incorrect because the patient's fear of going home and being alone does not necessarily indicate their ability to perform dressing changes independently. B: The patient can begin retaking all of the previous medications - This is incorrect as the fear expressed by the patient is related to being alone at home, not to medication management. D: The patient�s surgery was not successful - This is incorrect as there is no indication in the subjective data provided that the surgery was not successful.